PA Perioperative Consultation


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  • This talk is designed for housestaff and cardiology fellows, with a an orientation to equipping these folks for the types of questions asked on internal medicine and cardiology boards.
  • Several schemes for estimated perioperative risk have been used over the years. Although perhaps the most subjective, the American Surgical Association/Dripps classification is still commonly used by anesthesiologists. The Goldman Index was the first risk stratification method to use modern statistical methods and identified 9 clinical factors which correlated with cardiovascular risk and death. A weight was assigned to each risk factor based on the strength of the statistical risk and it was possible, using this method, to assign a number of points and use this point score, generally to place a patient in one of four risk categories. Although popular at the time, this was based primarily on the data from a single hospital (Mass General) and was subsequently shown to underestimate risk in certain populations, including the elderly, obese and those with vascular disease. The Detsky Index was a take-off of the Goldman Index which empirically added a number of additional clinical characteristics known to be associated with perioperative risk. Recommended today, and the focus of the remainder of this presentation are the joint recommendations of the AHA and ACC.
  • The urgency with which surgery is required has been shown to be an important predictor of risk. In fact, studies have shown that surgery performed on an emergent basis is associated with a 3-5 times increased risk compared with the same surgery conducted on an elective basis. Beyond the issue of urgency is the degree of risk arising from the type/complexity of surgery. Listed on this and the next two slides are the three categories of surgical risk and associated procedures. In general, it is most critical to remember the high risk procedures listed here, as these lead to special patient handling in the recommended algorithm to be presented shortly …. Notice that virtually all vascular surgery is considered high risk.
  • PA Perioperative Consultation

    1. 1. Perioperative Assessment Stanley Kurek, DO, FACS Associate Professor of Surgery UTMCK Dept. of Surgery
    2. 2. Goals <ul><li>Understand how to estimate peri-operative CV risk </li></ul><ul><li>Know when to perform stress testing preoperatively </li></ul><ul><li>Learn how to reduce risk perioperatively in those at higher risk </li></ul>
    3. 3. Key Points 1. Extensive testing is rarely needed to determine risk 2. Evaluation/Testing not needed if: a. Low risk surgery b. Good functional capacity and no cardiac symptoms c. No clinical risk factors
    4. 4. Key Points 4. Revascularization (surgery or PCI) should be considered only if standard indications are present 5. If PCI to be done, delay before non-cardiac surgery should be as follows: POBA: 14 days BMS: 30-45 days DES: > 365 days
    5. 5. Key Points 6. Cardiac complications (both ischemia and infarction) are often manifested by: a. Confusion, other MS changes b. Hypotension c. Dyspnea, heart failure 7. Cardiac complications tend to occur postoperatively and not intraoperatively, with a peak incidence on POD # 2-3
    6. 6. Key Points ST Depression Ref: Mangano, et al, JACC, 1991
    7. 7. Key Points <ul><li>8. Outcomes in high risk patients optimized with: </li></ul><ul><ul><ul><li>a. Beta blockers </li></ul></ul></ul><ul><ul><ul><li>b. Aggressive pain control </li></ul></ul></ul><ul><ul><li>c. Avoidance of severe anemia </li></ul></ul><ul><ul><li>d. Normothermia </li></ul></ul><ul><ul><li>d. Vigilant monitoring </li></ul></ul>
    8. 8. Perioperative Risk <ul><li>Patient </li></ul><ul><ul><li>Underlying disease </li></ul></ul><ul><ul><li>Physiologic Reserve </li></ul></ul><ul><li>Procedure </li></ul><ul><ul><li>Risk Classification </li></ul></ul><ul><li>Anesthetic Risk </li></ul><ul><li>Environment </li></ul>
    9. 9. Patient-associated Factors <ul><li>Underlying (comorbid) conditions </li></ul><ul><ul><li>More comorbidity = greater risk </li></ul></ul><ul><ul><li>Ischemic heart disease </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Renal Insufficiency </li></ul></ul><ul><ul><li>Low serum albumin </li></ul></ul>
    10. 10. Patient-associated Factors (cont.) <ul><li>Undiagnosed hypethyroidism </li></ul><ul><li>Hepatitis </li></ul><ul><ul><li>Acute, 10% mortality </li></ul></ul><ul><li>Cirrhosis </li></ul><ul><li>Obesity </li></ul>
    11. 11. Diabetes <ul><li>“ Heroic” efforts to control BS </li></ul><ul><li>Decreased postop M&M significantly in cardiac surgery </li></ul><ul><li>Must be aware of hypoglycemia </li></ul><ul><li>Poor wound healing </li></ul><ul><li>Postop infections </li></ul><ul><li>Diabetic comorbidities </li></ul>
    12. 12. Cerebral Vascular Disease <ul><li>Stroke Risk </li></ul><ul><li>Hypertensive vascular disease </li></ul><ul><li>Associated comorbidities </li></ul>
    13. 13. Obesity <ul><li>BMI (wt/ht)(m 2 ) </li></ul><ul><ul><li>BMI < 25 normal </li></ul></ul><ul><ul><li>BMI 25-30 overweight </li></ul></ul><ul><ul><li>BMI 31-40 obese </li></ul></ul><ul><ul><li>BMI > 40 morbidly obese </li></ul></ul>
    14. 14. Obesity <ul><li>Decreased pulmonary reserve </li></ul><ul><ul><li>Decreased FRC </li></ul></ul><ul><li>Wound infections </li></ul><ul><li>Anesthesia difficulties: </li></ul><ul><ul><li>Intubation </li></ul></ul><ul><ul><li>Venous access </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><li>Thrombophlebitis </li></ul><ul><li>Association with DM, CV disease and HTN </li></ul>
    15. 15. Patient Factors <ul><li>Renal function: </li></ul><ul><ul><li>Approximately 1% decline in functional nephrons per year after age 40 </li></ul></ul><ul><li>Pulmonary function: </li></ul><ul><ul><li>refer to text </li></ul></ul>
    16. 16. Overview <ul><li>Epidemiology </li></ul><ul><li>Risk Assessment </li></ul><ul><li>Preoperative Testing </li></ul><ul><li>Postoperative Management to Reduce Risk </li></ul><ul><li>Frequently asked questions </li></ul><ul><li>Case studies </li></ul>
    17. 17. Epidemiology <ul><li>43.9 million inpatient procedures annually </li></ul><ul><li>CV complications are the leading cause of morbidity and mortality following surgery </li></ul><ul><ul><li>Rates among all comers: 2% </li></ul></ul><ul><ul><li>>3 risk factors: 11% </li></ul></ul><ul><li>20 Billion dollar annual cost </li></ul>Source: CDC 2003 National Hospital Discharge Survey - Published July 8, 2005
    18. 18. Epidemiology Source: CDC 2003 National Hospital Discharge Survey - Published July 8, 2005
    19. 19. Distribution of Procedure by Gender Women Men Source: CDC 2003 National Hospital Discharge Survey - Published July 8, 2005
    20. 20. Hypercoagulable State Triggers <ul><li>Surgical Trauma </li></ul><ul><li>Anesthesia/analgesia </li></ul><ul><li>Surgical Trauma </li></ul><ul><li>Anesthesia/analgesia </li></ul><ul><li>Surgical Trauma </li></ul><ul><li>Anesthesia/analgesia </li></ul><ul><li>Intubation/extubation </li></ul><ul><li>Pain </li></ul><ul><li>Hypothermia </li></ul><ul><li>Bleeding/anemia </li></ul><ul><li>Fasting </li></ul><ul><li>Anesthesia/analgesia </li></ul><ul><li>Hypothermia </li></ul><ul><li>Bleeding/anemia </li></ul>↑ TNF- α ↑ IL-1 ↑ IL-6 ↑ CRP ↑ PAI-1 ↑ Factor VII ↑ Platelet reactivity ↓ antithrombin III ↑ catecholamine and cortisol levels ↓ oxygen delivery ↑ BP ↑ HR ↑ FFAs ↑ relative insulin deficiency Coronary artery shear stress Plaque fissuring ↑ Oxygen demand Myocardial Ischemia Acute Coronary Thrombus Perioperative Myocardial Infarction Plaque fissuring Inflammatory State Stress State Hypoxic State
    21. 21. Men and woman are not the same
    22. 22. Gender Differences in Heart Disease <ul><li>Woman get it at a later age </li></ul><ul><li>Woman are less likely to manifest with “typical” symptoms </li></ul><ul><li>Women have worse outcomes in cardiac intervention </li></ul><ul><li>Women (most) don’t have wives to take care of them! </li></ul>
    23. 23. Overview <ul><li>Epidemiology </li></ul><ul><li>Risk Assessment </li></ul><ul><li>Preoperative Testing </li></ul><ul><li>Postoperative Management to Reduce Risk </li></ul><ul><li>Frequently Asked Questions </li></ul><ul><li>Case Studies </li></ul>
    24. 24. Approaches to Risk Assessment <ul><li>ASA/Dripps </li></ul><ul><li>Goldman Multifactorial Index </li></ul><ul><li>Detsky Modified Index </li></ul><ul><li>Revised Risk Index </li></ul><ul><li>ACC/AHA Task Force Recommendations </li></ul>Quantitative Strategic
    25. 25. Dripps/ASA Classification Class Systemic Disturbance Mortality* 1 Healthy patient with no disease outside of the surgical process <0.03% 2 Mild-to-moderate systemic disease caused by the surgical condition or by other pathologic processes 0.2% 3 Severe disease process which limits activity but is not incapacitating 1.2% 4 Severe incapacitating disease process that is a constant threat to life 8% 5 Moribund patient not expected to survive 24 hours with or without an operation 34% E Suffix to indicate an emergency surgery for any class Increased
    26. 26. Goldman Risk Index Ref: Goldman M, Caldera D, Southwick, et al: Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 148:2120-2127, 1988.
    27. 27. ACC/AHA Guidelines J Am Coll Cardiol, 2007; 50:1707-1732
    28. 28. Stepwise Approach to the Pre-operative Evaluation
    29. 29. Stepwise Approach to Preoperative Cardiac Assessment Need for emergency noncardiac surgery Operating room Evaluate and treat per ACC/AHA Guidelines Vigilant perioperative and postoperative management Consider Operating Room Low Risk Surgery Active cardiac conditions No Yes Yes No Proceed with planned surgery Asymptomatic and good functional capacity Yes Proceed with planned surgery No Yes Manage based on clinical risk factors No
    30. 30. Manage based on clinical risk factors 3 or more clinical risk factors* 1 or 2 clinical risk factors* No clinical risk factors* Vascular Surgery Intermediate risk surgery Vascular Surgery Intermediate risk surgery Proceed with planned surgery Proceed with planned surgery with HR control or consider non-invasive testing Consider Testing *Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal insufficiency, cerebrovascular disease
    31. 31. Importance of Surgical Urgency Elective Surgery: Carried out at a time to suit the patient and surgeon Urgent Surgery: Carried out within 24-hrs of admission Emergency Surgery: Carried out within 2-hrs of admission or in conjunction with resuscitation Source: Evaluation of National Confidential Enquiry into Perioperative Deaths (NCEPOD) Non-Cardiac Surgery
    32. 32. Surgical Urgency? Key Point: Patients undergoing urgent or emergent surgery are at higher risk of postoperative complications and require closer surveillance postoperatively.
    33. 33. Functional Capacity <ul><li>Correlates with maximum oxygen uptake on treadmill testing </li></ul><ul><li>Demonstrated predictor of future cardiac events </li></ul><ul><li>Poor functional capacity may hide low threshold cardiac symptoms </li></ul>
    34. 34. Duke Activity Status Index <ul><li>1 MET Can you take care of yourself? </li></ul><ul><li>Eat, dress, or use the toilet? </li></ul><ul><li>Walk indoors around the house? </li></ul><ul><li>Walk a block or two on level ground at 2-3 mph or 3.2-4.8 km/h? </li></ul><ul><li>4 METs Do light work around the house like dusting or washing clothes? </li></ul><ul><li>MET = metabolic equivalent </li></ul><ul><li>4 METs Climb a flight of stairs or walk up a hill? </li></ul><ul><li>Walk on level ground at 4 mph or 6.4 km/h? </li></ul><ul><li>Run a short distance? </li></ul><ul><li>Do heavy work around the house like scrubbing floors or lifting or moving heavy objects? </li></ul><ul><li>Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? </li></ul><ul><li>10 METs Participate in strenuous sports like swimming, singles tennis, football, baseball, or skiing? </li></ul>
    35. 35. Assessing Risk
    36. 36. Active Cardiac Conditions Surgery <ul><li>Acute or recent MI (7-30 d) </li></ul><ul><li>Unstable coronary syndrome </li></ul><ul><li>Decompensated CHF </li></ul><ul><li>Significant Arrhythmias </li></ul><ul><li>Severe Valvular Disease </li></ul>High Risk:
    37. 37. Clinical Risk Factors 3 or more risk factors & Vascular surgery <ul><li>History of heart disease </li></ul><ul><li>Compensated or prior CHF </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Renal Insufficiency </li></ul>Proceed Cautiously with: Consider testing 1 – 2 risk factors Proceed with surgery or consider testing
    38. 38. Low Risk Situations Reasonable to proceed with surgery <ul><li>Low risk surgery </li></ul><ul><li>Good functional capacity </li></ul><ul><li>No cardiac symptoms </li></ul><ul><li>No “active cardiac conditions” </li></ul><ul><li>No clinical risk factors </li></ul>Low Risk:
    39. 39. Surgery Related Risk <ul><li>High Risk (Risk > 5%): </li></ul><ul><li>Emergent major operations </li></ul><ul><li>Aortic and other major vascular </li></ul><ul><li>Peripheral vascular </li></ul><ul><li>Anticipated prolonged or associated with large fluid shifts and/or blood loss </li></ul><ul><li>Intermediate Risk </li></ul><ul><li>(Risk < 5%): </li></ul><ul><ul><li>Carotid endarterectomy </li></ul></ul><ul><ul><li>Endovascular AAA repair </li></ul></ul><ul><ul><li>Head and neck </li></ul></ul><ul><ul><li>Intraperitoneal and intrathoracic </li></ul></ul><ul><ul><li>Orthopedic </li></ul></ul><ul><ul><li>Prostate </li></ul></ul><ul><li>Low Risk Surgery (Risk < 1%): </li></ul><ul><ul><li>Endoscopic procedures </li></ul></ul><ul><ul><li>Superficial procedure </li></ul></ul><ul><ul><li>Cataract surgery </li></ul></ul><ul><ul><li>Breast surgery </li></ul></ul>
    40. 40. Overview <ul><li>Epidemiology </li></ul><ul><li>Risk Assessment </li></ul><ul><li>Preoperative Testing </li></ul><ul><li>Postoperative Management to Reduce Risk </li></ul><ul><li>Frequently Asked Questions </li></ul><ul><li>Case Studies </li></ul>
    41. 41. Preoperative Testing Negative Predictive Value Freedom from MI or Death Eagle et al. JACC 1996;27:910.
    42. 42. MI or Death Preoperative Testing Positive Predictive Value
    43. 43. ACC/AHA Recommendations <ul><li>Echocardiography: </li></ul><ul><ul><li>Dyspnea of unknown origin (Class IIa) </li></ul></ul><ul><ul><li>Current or hx of HF and no echo in 12 months (Class IIa) </li></ul></ul><ul><li>12 Lead ECG </li></ul><ul><ul><li>Vascular surgery and 1 CRF (class I) </li></ul></ul><ul><ul><li>CRFs and intermediate risk surgery (class I) </li></ul></ul><ul><ul><li>All vascular surgery (class IIa) </li></ul></ul>
    44. 44. ACC/AHA Recommendations <ul><li>Treadmill stress testing </li></ul><ul><ul><li>High cardiac risk conditions </li></ul></ul><ul><ul><li>3 CRFs, poor functional capacity & vascular surgery (class IIa) </li></ul></ul><ul><li>Nuclear stress testing </li></ul>
    45. 45. Which test to choose? Most ambulatory patients Abnormal resting ECG (dig, LVH) LBBB Unable to exercise Treadmill Stress Test Exercise echo or sestamibi DSE Adenosine sestamibi dipyridamole sestamibi
    46. 46. Overview <ul><li>Epidemiology </li></ul><ul><li>Risk Assessment </li></ul><ul><li>Preoperative Testing </li></ul><ul><li>Postoperative Management to Reduce Risk </li></ul><ul><li>Frequently Asked Questions </li></ul><ul><li>Case Studies </li></ul>
    47. 47. Perioperative Management <ul><li>Revascularization </li></ul><ul><li>Beta blockers </li></ul><ul><li>Statins </li></ul><ul><li>Alpha-2 agonists </li></ul><ul><li>Calcium channel blockers </li></ul>
    48. 48. PCI before anticipated surgery Acute MI High Risk ACS High risk anatomy Stent and continued Dual-antiplatelet rx Bleeding risk of anticipated surgery Balloon angioplasty Bare-metal stent Drug-eluting stent 14 to 29 Days 30 – 365 Days > 365 Days Low Not low
    49. 49. Timing of Surgery After PCI Balloon angioplasty Bare-metal stent Drug-eluting stent < 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days Delay Surgery with ASA Delay Delay Surgery with ASA Surgery with ASA
    50. 50. Postoperative Mortality Reduction Beta-Blockers <ul><li>200 pts undergoing non-cardiac surgery </li></ul><ul><li>Random assignment to: </li></ul><ul><ul><li>IV followed by oral atenolol or </li></ul></ul><ul><ul><li>Placebo </li></ul></ul><ul><li>Double-blind follow-up over 2 years </li></ul>Mangano, et al. NEMJ 1996;335:1713. Mortality
    51. 51. Postoperative Cardiac Events In High Risk Patients Bisoprolol n=59 Placebo n=53 Poldermans et al. NEJM 1999;341:1789. <ul><li>173 patients undergoing vascular surgery with positive DSE </li></ul><ul><li>Randomized to BB 1 week pre-op or placebo </li></ul><ul><li>Followed for 30 days </li></ul>
    52. 52. Perioperative Beta Blockers AHA/ACC Recommendations: 2006 Update <ul><li>Beta blockers required in recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension </li></ul><ul><li>Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery </li></ul><ul><li>Patients undergoing vascular surgery and with identified CAD </li></ul><ul><li>Vascular surgery and multiple cardiac risk factors </li></ul><ul><li>Moderate or high risk surgery and multiple cardiac risk factors </li></ul>Key Point: if known or suspected CAD and undergoing moderate or high risk surgery, use a beta blocker!
    53. 53. Perioperative Nitrates? Dodds, et al. Anesth. Analg. 1993;76:705-13 ACC/AHA 2007 Recommendations: Nitrates Class I: None Class IIa: None Class IIb: Can consider in context of anesthetic plan and patient hemodynamics
    54. 54. Perioperative Statins? <ul><li>100 patients pre-op before vascular surgery </li></ul><ul><li>Random assignment: </li></ul><ul><ul><li>Atorvastatin 20 mg </li></ul></ul><ul><ul><li>Placebo </li></ul></ul><ul><li>Started 30 days preoperatively </li></ul><ul><li>Follow-up 6 month </li></ul><ul><li>Endpoint: </li></ul><ul><ul><li>Cardiac death </li></ul></ul><ul><ul><li>Non-fatal MI </li></ul></ul><ul><ul><li>USA </li></ul></ul><ul><ul><li>Stroke </li></ul></ul>J Vasc. Surgery 2004;39:967
    55. 55. Perioperative Statins Hindler, et al. Anesthesiology 2006;105:1260-72 ACC/AHA 2007 Recommendations: Statins Class I: Patients currently taking statins Class IIa: Patients undergoing vascular surgery Class IIb: Patients with at least 1 clinical risk factor undergoing intermediate risk surgery
    56. 56. Treatment of Anemia? <ul><li>There is a direct relationship between preoperative anemia and risk of complications (CV complications, infection, mortality), especially if known CAD </li></ul><ul><li>Decline in Hbg associated with increase in mortality, especially in those with CV disease </li></ul><ul><li>Benefits of transfusion have not been proven </li></ul>
    57. 57. Preoperative Hgb and Mortality Carson, et al. Lancet. 1996;348:1055-60 Study of Untreated Anemia
    58. 58. Perioperative Hypothermia <ul><li>300 pts undergoing general surgery </li></ul><ul><li>Randomized, double blinded assignment to routine care or supplemental warming </li></ul>Frank SM JAMA 1997;227(14) ACC/AHA 2007 Recommendations: Normothermia Class I: For most procedures except during periods in which mild hypothermia is intended for organ protection
    59. 59. Key Point: <ul><li>Beta blocker if able </li></ul><ul><li>Limit hypothermia </li></ul><ul><li>Aggressive post-operative pain control </li></ul><ul><li>Avoid significant anemia </li></ul>Avoid Sympathetic Stimulation in those at Risk!
    60. 60. Overview <ul><li>Epidemiology </li></ul><ul><li>Risk Assessment </li></ul><ul><li>Preoperative Testing </li></ul><ul><li>Postoperative Management to Reduce Risk </li></ul><ul><li>Frequently Asked Questions </li></ul><ul><li>Case Studies </li></ul>
    61. 61. FAQs <ul><li>ICDs should be turned off immediate preoperative and turned on immediately postoperatively. </li></ul><ul><li>Pacemakers can be left on perioperatively but should be interrogated pre- and post-op. </li></ul>How should I handle the patient with a pacemaker or implantable defibrillator (ICD)?
    62. 62. FAQs <ul><li>In general, at least one month. </li></ul><ul><li>In patients treated with PCI, delay based on type of treatment: </li></ul><ul><ul><li>POBA: 14 days </li></ul></ul><ul><ul><li>BMS: 30 days </li></ul></ul><ul><ul><li>DES: 365 days </li></ul></ul>How long should surgery be delayed after a myocardial infarction?
    63. 63. FAQs <ul><li>If rate controlled, it is not a reason to delay surgery or expect problems. </li></ul><ul><li>If on warfarin, should communicate with PCP or cardiologist about safety of discontinuing. </li></ul>How should I handle the patient with atrial fibrillation?
    64. 64. FAQs <ul><li>Low risk patients (bileaflet Aortic valve, no risk factors) </li></ul><ul><ul><li>Stop warfarin 48-72 pre-op </li></ul></ul><ul><ul><li>Resume 24 hrs post-op </li></ul></ul><ul><li>High risk patients (mitral valve, aortic valve + any risk factor) </li></ul><ul><ul><li>Bridge with UFH, starting when INR < 2 </li></ul></ul>Can anticoagulation be stopped in the patient with a mechanical heart valve? Risk factors: AF, previous thromboembolism, LV dysfunction, hypercoagulable state, older generation valve, mechanical tricuspid valve, more than one mechanical valve
    65. 65. Questions?